Alcohol Treatment

There are many types of therapy that are helpful for alcohol abuse disorders.
The most commonly used are cognitive behavioral therapy (CBT) and
motivational interviewing. Dialectical behavioral therapy is also gaining
popularity.

There is also relapse prevention therapy, which is an adaptation
of CBT techniques specifically for substance abuse.

MOTIVATIONAL INTERVIEWING

Motivational interviewing (MI) was first developed for treating alcohol
users, but it has since proven helpful for patients with a variety of psychiatric
disorders. Its purpose is to help patients become aware of their intrinsic
motivation to change their problematic behaviors.

Stages of Change
The MI technique entails spending quite a bit of time assessing how ready
you are to make significant changes. The Stages of Change model is
a helpful theoretical framework to keep in mind. According to the model, there are five
stages of change: pre-contemplation, contemplation, preparation, action,
and maintenance.

Stages of Change
Pre-contemplation Unaware that there is a problem
Contemplation Aware of a problem, but not ready to change; will ask
for information
Preparation Considering a behavior change in the near future; will
ask for advice
Action Making a behavior change
Maintenance Successfully changed behavior; using less energy to
maintain the gains that have been made

RELAPSE PREVENTION THERAPY
Relapse prevention therapy (RPT) has been shown to be effective for various
substance use disorders . There are formal procedures for this type of
therapy, often involving group sessions with structured activities. But the
essence of the approach can be applied during short individual visits, and
I suggest you budget some time during every meeting to discuss relapse
prevention techniques. A good way to open that conversation is by asking
questions such as: “Do you see any barriers that would be a problem to your
recovery?” “Is there something that could derail the train here?” “What are
your concerns and thoughts about abstinence? Are there any challenges?”

The key to relapse prevention is planning ahead. Have patients envision
scenarios where they might be tempted to use, like going to a party or walking
down a street and meeting their former dealer. Have them talk through
their plans for dealing with these kinds of situations. Often, you will help
patients develop “refusal skills,” which are strategies for successfully turning
down opportunities to use substances. You can elicit refusal skills by saying,
“Give me some examples of what you could say [or do] in these risky
situations. What words would you actually use?”
Example of refusal skills include:
• Saying, “No thank you, I’m not going to use because . . .” Coming up with
a list of specific excuses ahead of time helps patients resist peer pressure
and harden their resolve.
• Saying, “Not right now” or, “Maybe another time.” This is sometimes
easier than saying no because these phrases sound less judgmental about
the offer.
• Changing the subject.
• Suggesting an alternative activity

Common causes of relapse
Some of the most common reasons for relapse are self-medication, temptation,
overconfidence, and boredom. I discuss each of these reasons below,
along with suggestions for how to help your patients work through them.

Self-medication
Patients recognize that using drugs helps them deal with stress, at least on a
temporary basis. It’s your job to help them come up with some alternative
solutions. For example, I had a patient who said, “My mother-in-law is
coming to visit next week, and I always drink more when she’s around.” My
response was to ask what made him drink more when she was visiting. He
described some sources of chronic conflict and tension between the two of
them. I offered a few commonsense suggestions to offset self-medication,
such as:
• Enlisting his spouse’s help. “Tell your partner that you’re trying not to
drink while enduring a visit with a particularly stressful person. The two
of you can come up with ways ahead of time to try and defuse some of the
tension. Or perhaps your spouse could just give you a simple reminder
that your goal is abstinence.”
• Avoidance. “Find excuses to attend to some matters in another part of the
house or make plans to be out of the house for a while.”
• Considering timing. “Perhaps you should delay your quit attempt until
after a potentially stressful visit or plan a visit when your sobriety is better
established.”

Temptation (“because it’s there”)
When patients expose themselves to temptation, they are asking for
trouble. Otherwise known as “triggers,” these are situations that make it
harder for your patient to abstain. These include going to the bar or even
driving by it on the way home, walking through a neighborhood where
one is likely to interact with drug dealers, or spending time with certain
people who use drugs. I will often have patients write down a list of such
triggers and discuss how to avoid them or cope with them successfully.
This is sometimes referred to as “avoiding people, places, and things” (that
are triggers to use).
For example, a patient’s job required him to go to social functions where
alcohol was served. He worried that others would notice if he didn’t drink
and would suspect that he had a drinking problem (he did, but it wasn’t
something he wanted to advertise!). He would feel self-conscious in these
scenarios and sometimes would feel obligated to drink. Some suggestions
we discussed included:
• Do some reality testing: “If you didn’t have a drink, would this really be
such a terrible thing for your job?” “How likely is it that your colleagues
are keeping track of what you are ordering?”
• Think of specific excuses or explanations ahead of time (ie, refusal
skills)—for example, “I’ll tell them my doctor said I shouldn’t drink
because of heartburn pain.”
• Substitute a nonalcoholic beverage and nurse this drink throughout the
social function.

Overconfidence
Patients who have been abstinent for a while can become overconfident
in their ability to use in a controlled way. They start thinking about the
good times and tell themselves, “Using once in a while won’t hurt.” Unfortunately,
this attitude often leads to relapse. You want to find out about
patients’ rationale and help play up the ambivalence. They may have a
romanticized ideal about what life was like when they were using. Carefree
use might seem appealing. Remind them that it wasn’t all days of wine and
roses; there were plenty of consequences that led them to make the change
in the first place.

Some patients will rationalize that they can have a few drinks at a particular
event, like a wedding or a sports game, and that compartmentalizing
their drinking in this way won’t lead to relapse. In these instances, I’ll ask:
“Are there particular reasons why you are having these thoughts of drinking
at this point in time?” “Is drinking appealing to you just because of this[wedding, anniversary party, etc], or are you having more cravings?” “Have
you been feeling more anxious or depressed about something?”
While I never tell patients that a return to controlled use is out of the
question, I will let them know that it’s unlikely to work out. I’ll say, “In my
experience, controlled use doesn’t work very well. That has not been an
achievable goal for most of my patients.”

FUN FACT: Nonalcoholic Beers
Nonalcoholic beers, by law, can actually contain a
small amount of alcohol (0.5% or less). This is why they
are also referred to as low-alcohol beer or near-beer. Because they
have such a low alcohol content, these drinks can also legally be
sold to minors.

Nonalcoholic beer is brewed like regular beer, but before bottling
it, there is an extra heating step to remove the alcohol, since alcohol
has a lower boiling point than water and will boil off first. The
heating process may, however, change the flavor of the beer, which
is a common complaint. Websites such as beeradvocate.com have
reader reviews from across the spectrum of nonalcoholic beers. So
if your patient’s main argument against these drinks (besides the
obvious) is that “they taste like fizzy yellow water,” suggest looking
up the reviews and trying some other brands.

Boredom
Most patients in recovery realize that they need to stay busy and focused on
things, like work, hobbies, and volunteering. I find that folksy metaphors
sometimes work well: “The devil finds work for idle hands.” Talk about
old hobbies that might be worth revisiting now that your patient is feeling
healthier and has more free time. Some people feel better when they dive
into a new situation or hobby with a group of people unrelated to their former
lifestyle choices. And some patients feel rewarded by getting involved
in sponsor roles or efforts to support others with substance use issues,
though for others this may hit too close to home. Keep a dialogue going
about how patients are filling their time.

Advice From Terence Gorski, an Expert on Relapse Prevention
(Adapted from an article written by Terence Gorski for the Carlat
Addiction Treatment Report, November 2013. Mr. Gorski is the
founder and president of The CENAPS Corporation.)
I will often have clients write down their life and addiction history
and look at why they relapsed in the past. I will then have them
develop a list of early warning signs of impending relapse. These
would include things like irrational thoughts and unmanageable feelings,
as well as situations, such as hanging around with old drug-using
peers, that may lead them back to substance use.
We will then work together to put into place strategies for preventing
relapse. These include detailed daily planning and personal
check-ins with sponsors, friends, or family members, to make sure
they are keeping with the program. I will have clients write a “recovery
plan”—a schedule of activities that they know will help them
stay sober, such as working a 12-step program and attending relapse
prevention support groups—and compare it to the list of high-risk
situations and early relapse warning signs. What will clients do when
faced with a high-risk situation? Techniques include mental rehearsal,
role-playing, and therapeutic assignments. For example, if a client
goes into a bar where he used to drink, he will plan to call his AA
sponsor and go to the next available AA meeting.

I recommend that clients start each day by reading something that
focuses the mind on sober and responsible living and then mindfully
planning the day. They should end the day by confirming that they
completed everything on the recovery plan and reflecting on how
they dealt with various challenges. If there are issues, clients then
decide whether to tap into their support network to talk about the
day before going to bed.

It’s crucial to schedule recovery checkups with clients to review
and update the relapse prevention plan. At minimum, I recommend
monthly visits for 3 months, quarterly visits for the next 2 years, and
then annual visits for at least the next 5 years. (A detailed clinical manual,
“Recovery Management Check-Ups: An Early Re-Intervention
Approach,” is available at http://tinyurl.com/j5bfzu5.)
Journaling for relapse avoidance
I encourage most of my patients to journal, and I emphasize its importance
in the recovery process. I keep my instructions simple and say something
like, “You need to write a half a page a day, and I want you to bring your
notebook to each visit.”

There are multiple benefits to journaling:
• Writing things down helps my patients get a clearer sense of how their
lives are going.
• I have a better idea of what’s running through their heads.
• As time goes on, I can review past entries with patients to demonstrate
how much better things are getting.
• Journaling helps alert me to situations we aren’t discussing in the office,
usually related to relationships—a patient’s entries can sometimes reveal
an enabler.
• For those in AA, I can discern what they are getting out of the meetings,
and what they are learning from the Big Book of AA.